Special report:

The SARS epidemic

China wakes up

A health scare may herald much more profound changes

AT BEIJING'S international airport, a parting couple hug and press their mask-covered mouths together in a prophylactic kiss. On the streets of the capital, mask-wearing is fast becoming the norm. Outside foreign embassies, armed police have been reinforced with a new contingent of guards clad in masks and gloves. After weeks in denial, Beijing is suddenly confronting the problem of Severe Acute Respiratory Syndrome, or SARS.

This virus, though less infectious than influenza, is more than twice as deadly as influenza in a pandemic. Its mortality rate, at around 5%, is close to that of bacterial meningitis; and, like meningitis, it gains in horror by killing the young and vigorous as well as the old and frail.

Five months after the first appearance of SARS in the southern province of Guangdong, something snapped at the end of last week. On April 18th, the government information office invited the foreign media to attend a briefing on SARS, to be given two days later by the health minister and the mayor of Beijing. But neither showed up. They had been dismissed—the party's first public sacking of top officials in mid-crisis for incompetence, rather than political incorrectness.

The most senior official to attend was a deputy minister of health, Gao Qiang, who announced that there were 339 confirmed SARS cases in Beijing and another 402 suspected cases, compared with a mere 37 confirmed cases (and an undisclosed number of suspected cases) declared previously. By the 24th, confirmed cases in the city had risen to 774, with another 863 suspected and 39 deaths. This compared with 49 fatalities and 1,359 confirmed cases in the worst-affected area (by official counts), Guangdong. Beijing alone now accounts for a third of all China's reported deaths from SARS.

The upcoming week-long May Day holiday—normally a time when millions travel in crowded trains and buses—was promptly cancelled. Transport operators were ordered to screen out passengers showing possible signs of SARS, such as fever and persistent coughing. Citizens were advised to avoid crowded areas and warned they would be quarantined if they had contact with a SARS patient. On Wednesday, schools in the capital were ordered to close for two weeks.

Why the change of tack? Not out of concern for public health, to be sure; the central government is still lethargic in the face of the far bigger problem of HIV/AIDS, which, according to a report by the Centre for Strategic and International Studies (CSIS) in Washington, may result in between 10m and 20m Chinese being HIV-positive within seven years. More important to the leaders was the damage being done to China's image abroad, and the realisation that the economic consequences of being honest may, in the long run, be less severe than those of obfuscation.

Even before the higher figures began to leak out, international events in Beijing were being cancelled because foreigners were refusing to attend and foreign tour-groups were staying away. Dependants of foreigners living in Beijing were beginning to leave the country. China's cover-up of the spread of SARS was causing the country's biggest credibility crisis abroad since the crushing of the Tiananmen Square protests in 1989. On April 23rd, compounding the regime's fears, the WHO advised travellers not to go to Beijing—advice not heard since those violent days.

Finding scapegoats

At home, the credibility of China's new leaders, who took office at a party congress last November and a parliamentary session in March, is also at stake. The president and party chief, Hu Jintao, and the prime minister, Wen Jiabao, have been trying to present themselves—as new leaders do, even here—as men attuned to the feelings of ordinary citizens. They have been failing. Hence the unaccustomed rolling of at least a few official heads.

Cynics say, however, that the ousted officials were scapegoats for policymaking errors at a higher level and for the ingrained weaknesses of China's sclerotic and secretive bureaucracy. Bates Gill of the CSIS says the ousted health minister was “a breath of fresh air”, who helped secure the release of an activist detained last year for revealing a secret document on the spread of HIV in China. Neither of the dismissed officials was responsible for the decision to order a news blackout on the development of SARS as it spread across Guangdong in February and reached the capital in March.

The two-week annual session of parliament, which began on March 5th, was an event that no leader wanted marred by panic over a disease. The party controls the media through secret directives issued by the party's Propaganda Department, which is overseen by a member of the Politburo's Standing Committee. The Standing Committee, headed by Mr Hu, would have known about the decision to suppress news coverage of SARS, as well as to avoid preventive measures in Beijing that might alert the public to the problem.

It was not until April 2nd that China's cabinet, headed by Mr Wen, held its first meeting to discuss the SARS problem. This might have been a good time to sideline the health minister, Zhang Wenkang, if he was felt to be underperforming, but instead he was put in charge of SARS prevention. At a news conference the next day, Mr Zhang told a correspondent that “The ordinary people of the mainland are not like the ordinary people of Hong Kong. Their education level is lower. If we released information like they did in Hong Kong, there would be chaos.” Mr Zhang would hardly have made such a remark if Mr Wen had told him to be completely open about the epidemic.

And then there is Jiang Zemin, Mr Hu's predecessor, who is still the country's most powerful man as commander-in-chief of the armed forces. There is little evidence that Mr Jiang has played a significant role in handling the SARS crisis. If he had, the problem in Beijing might have been a little easier to tackle. Of Beijing's 175 hospitals, 16 are under the control of the armed forces and, until last week, were under no obligation to report SARS cases to the city authorities (even though, with their often superior facilities, they are a magnet for military and civilian patients alike). But though bringing such hospitals to heel may help in gathering statistics, their previously separate status does not help explain why Beijing's SARS figures were so seriously understated. The only plausible reason is that people were lying.

The health ministry said on Sunday that it knew of no deliberate cover-ups, but one of the more daring official newspapers has suggested otherwise. The China Business Times accused the Beijing city authorities of “making false reports” and in another article said provincial authorities were giving tardy, incomplete and falsified figures in order to avoid blemishing the careers of officials. Lying is endemic in China's bureaucracy, partly because leaders at all levels are fearful that any mishap reported in their jurisdiction may be used as an excuse to pass them over for promotion or have them dismissed.

The China Business Times also pointed out the discrepancy between the government's decision last weekend to scrap the week-long May Day holiday (citizens will still get one day off) and a statement on April 6th by a senior tourism official that China should take advantage of the movement of tens of millions of holidaymakers around May Day to demonstrate that China is “the safest tourist destination”. Again, the official was presumably speaking in the knowledge that the prime minister would fully agree with him. Mr Wen, it appeared, was determined to play the crisis down and pretend that all was normal, even as Beijing's hospitals were struggling with an upsurge of cases.

Town and country

On roads leading into Beijing's neighbouring province of Hebei, officials have begun stopping some vehicles to check passengers for signs of SARS to prevent the disease from spreading. But such measures have come too late. Official figures show that SARS has now affected 20 of the country's 31 provinces and municipalities. Apart from Guangdong, Beijing and the northern province of Shanxi, each has reported only a tiny handful of cases. Tianjin, the port city closest to Beijing, has reported only eight, the whole of Hebei province has declared only six and Shanghai a mere two. But it is safe to assume that the actual number of cases around the country is significantly higher. With the best will in the world, cash-strapped local governments whose health-care and disease-surveillance systems have fallen into disarray in recent years for want of funds would be extremely hard pressed to monitor the spread of a new disease.

Even in Beijing, the official figures still convey only a partial picture. The city has offered free treatment for poor SARS patients. But this is little consolation to the large numbers with no health insurance, particularly the unemployed and the 3m or so ill-paid migrant labourers (about one-fifth of the city's population) who are too poor to consider hospital treatment in the city. Many with SARS-like symptoms would think twice about any offer of free treatment, since their ailment may well turn out to be something else for which they would have to pay. Compounding this fear is the risk that days of quarantine for themselves and family members could cause a big loss of earnings.

In rural areas, the situation is particularly bleak. The “barefoot-doctor” system established under Mao Zedong to provide basic health care to peasants has broken down. Many township hospitals can now do little more than dispense medicine. As many as 70% of country people cannot afford to pay for medical treatment. On Sunday, the deputy health minister said that if SARS was found to be spreading in the countryside, “the consequences would be extremely serious.” But how will anyone know? On April 23rd the government announced a fund of 2 billion yuan ($240m) to support anti-SARS work in the countryside and among the urban poor. The problem, however, could only be solved by a massive overhaul of the health-care and insurance system that would cost many times more than that.

With their political U-turn, Mr Hu and Mr Wen may help to shore up their image. In Beijing, the party's legitimacy rests largely on its ability to deliver economic growth. Although a severe downturn could precipitate serious social unrest, China's SARS crisis (unlike Hong Kong's) occurs at a time of strong growth. As long as the death toll does not rise (or is not rumoured to rise) dramatically in key urban areas such as Beijing and disruption is short-lived, the new leadership will probably muddle through. But the trust of the rest of the world, which had come to believe that China was beginning to understand the need to play by international rules, could take far longer to repair.